The Objective Assessment

Introduction to the Objective Assessment

Some factors of the objective assessment include what a clinician:

• Hears from the patient
• Feels physically on the patient
• Sees on the patient

Clinicians begin with a neurological assessment then move onto the cardiovascular assessment, progressing system by system. The various assessments include:

• Neurological assessment
• Cardiovascular assessment
• Respiratory assessment
• Gastrointestinal assessment
• Genitourinary assessment
• IV site assessment
• Safety assessment

Related Video – Health Assessment: The General Survey and Subjective Data

The Neurological Assessment

To perform a neurological assessment, a clinician checks:

• The level of consciousness, or how awake the patient is.
• Mental status, or whether they are oriented or confused.
• PERRLA, meaning “pupils, equal, round, reactive to, light, and accommodation.”
• Extraocular movements, or the six cardinal fields of gaze. They’re either intact or not.
• Pupil size. Most patients score a two on the pupil scale. 
• Grip strength and leg strength. Clinicians aren’t checking for strength. Instead, they want to ensure the patient’s grip is equal on both sides. If it is unequal, the patient may be experiencing a stroke.

The following dialogue is a hypothetical neurological assessment between a nurse and a patient named William. 

The nurse first assesses the level of consciousness and finds that William is very awake and alert in his hospital bed. 

Next, the nurse assesses mental status, asking questions orienting to person, place, time, and situation. The conversation might sound like this:

Nurse: Can you tell me your name?

Patient: William.

Nurse: Can you tell me the month and year?

Patient: September 2020.

Nurse: Can you tell me where you are right now?

Patient: The hospital.

Nurse: What brought you into the hospital?

Patient: A basketball injury.

Sometimes, the patient may be unable to tell the clinician what happened to them, indicating they’re not oriented to the situation.

As part of the neurological assessment, a clinician checks if the patient is oriented to person, place, time, and situation.

Next is PERRLA. The nurse has the patient look at their nose while shining a penlight in the patient’s eyes. The patient must look at the nurse’s nose to protect their eyes from the light. The following are tips for performing PERRLA:

• Come in from one side of the face and shine the light at the patient’s eye, making sure the pupil constricts before repeating with the other eye.
• Check pupil size to see if the pupils equally contract to light, satisfying PERRLA’s “reactive to light” requirement.
• Have the patient focus on a close-up object that is gradually moved away from them. Checks the pupils for dilation as the object moves away. As it moves closer, the patient’s pupils should constrict. 
• Finally, check for extraocular movements (EOMs) using the six cardinal fields of gaze. The patient follows the pen up and down, to the sides, and then diagonally. If the patient follows the pen without moving their head, their EOMs are intact.

During the PERRLA assessment, pupils constrict when exposed to a penlight.

Next, the nurse checks grips and leg strength. They ask the patient to squeeze their hands, checking for equality of strength. The nurse asks the patient to push their feet against the physician’s hands, again checking for equality of strength. A patient exhibiting unequal hand or feet strength may be experiencing a stroke, so it’s important the nurse checks both.

The Cardiovascular Assessment

To perform a cardiovascular assessment, the clinician will:

• Listen to the heart sounds.
• Feel for peripheral pulses.
• Feel skin temperature and moisture.
• Inspect skin color. A patient appearing gray is probably in poor cardiac health.
• Check capillary refill time, which is ideally fewer than three seconds.

Heart Sounds

A clinician listens to five places for heart sounds:

1. Aortic
2. Pulmonic
3. Erb’s point
4. Tricuspid
5. Mitral

Clinicians should place their stethoscope where that particular valve sends blood. For example, they place the stethoscope at the aortic point to listen to the aortic valve. The mitral valve is the point of maximum impulse, and it’s where physicians listen for an apical pulse.

Next, the clinician documents if there are any murmurs. If there aren’t, they document S1 and S2 noted without a murmur.

Heart auscultation involves listening to the valves.

Read: Health Assessment: The General Survey and Subjective Data

Peripheral Pulses

To check the peripheral pulse, clinicians assess the radial pulse on a scale of one to four. A one is weak and thready while a four is pounding.

Most patients have a radial pulse of two-plus, while their pedal pulse in the distal extremities is weaker due to reduced circulation, especially in older patients.

Clinicians feel for pedal pulses on top of the bone at the top of the foot. If a pulse isn’t felt, they feel for the posterior tibial pulse, which is on the inner part of the ankle. If there’s no posterior tibial pulse, the clinician must use a doppler. 

While checking pedal pulse, clinicians should also feel for peripheral edema. Edema is generally most prominent around the ankle area.

Clinicians feel for the dorsalis pedis or posterior tibial when checking for pedal pulses.

Skin Temperature and Moisture

The next part of the cardiovascular assessment is skin temperature and moisture. A patient with warm skin has adequate circulation, while a patient with cool, clammy skin may have problems with circulation and should be further evaluated. A patient with visibly blue or purple skin or mucous membranes is not receiving enough oxygen.

Capillary Refill Time

Clinicians check capillary refill time by depressing the patient’s finger nail bed and watching for the color to return. It should take less than three seconds. Clinicians can check the capillary refill time on the fingers or toes.

Respiratory Assessment

Clinicians listen to lung sounds when performing a respiratory assessment. It may be challenging if the patient is so sick they can’t sit forward, preventing the physician from listening to their back. It’s important that physicians listen to the patient’s back because they may catch sounds such as crackles in the posterior lobes, which won’t be heard in the anterior lobes.

Physicians should compare the lung sounds on both sides and have the patient breathe through the mouth to amplify sound. 

Clinicians begin listening at the upper part of the back, right below the neck. Clinicians may also listen to the lateral lobes. It is important to remember that the right lung has three lobes.

The right lung has three lobes, while the left lung has two lobes.

The other parts of the respiratory assessment are:

• Counting respirations
• Observing for distress and use of accessory muscles
• Checking for labored breathing
• Assessing if the patient is on oxygen or room air

Clinicians should document the rest of the respiratory assessment in their findings.

Related Video – Understanding a BLS Assessment

Gastrointestinal Assessment

The GI assessment is unique because it requires auscultation and palpation.

The abdominal region is divided into four quadrants. Right and left are based on the patient’s orientation.

To perform a GI assessment:

• Visually inspect the abdominal area, checking for any visible peristalsis, which is when the abdomen visibly moves on its own. Peristalsis denotes some sort of hyperactive processes, such as a bowel obstruction.
• Auscultate in all four quadrants, documenting bowel sounds as active, hyperactive, or hypoactive.
• Palpate the abdomen and document any tenderness.

If the GI assessment is normal, clinicians document “bowel sounds active in all four quadrants, abdomen soft and nontender to palpation.”

Genitourinary Assessment

To perform a genitourinary assessment, clinicians palpate for bladder distension if the patient has trouble voiding.

If the patient has a Foley catheter, clinicians observe the urine to document its color and character. Physicians should note whether it is amber, cloudy, clear, or yellow, as well as if the urine drains to the bedside bag. If the patient uses a urinal, clinicians still document the urine’s color and character.

A foley catheter is a tube inserted into the bladder to drain urine.

Assessment of the IV Site

Clinicians check the IV site for signs of infection. They document if the IV site has any redness, edema, or pain which indicates infection or infiltration. 

Physicians will also document what type of IV fluids are infusing and verify that the IV is patent and that medications and fluids are flowing as intended through it.

A red, swollen, or painful IV site may indicate an infection.

Safety Assessments

To finish the documentation and safety assessment, clinicians ensure:

• The bed is in the lowest locked position.
• The side rails are up on both sides of the bed.
• The call light is in reach.
• The patient is not in pain or with other unmet needs.
• All fall precautions are present.
• The bed alarm is active and the patient’s bracelet is on.

Summary

Clinicians perform an objective assessment on every admitted patient. The assessment includes a range of clinician observations. The assessments performed are neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, IV site, and safety.